Health inspection·May 24, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to apply a vehicle safety restraint during transportation in the facility van for one of three (R1) residents reviewed for falls on the sample list of three. This failure resulted in R1's wheelchair flipping backwards in the facility van during transport and R1 sustained a left side rib fracture. Findings Include: The Motor Vehicle Safety Program dated January 2025 documents seat belts and shoulder harnesses (occupant restraint systems) must be worn or used whenever the vehicle is in operation. The vehicle may not move until all passengers have fastened their restraints. R1's Fall Follow-up Note dated 5/15/25 documents R1 fell from his wheelchair while in the facility van. R1 was being transported back to the facility and his wheelchair was not properly secured. The root cause of the fall was determined to be the wheelchair was not properly secured. R1's Incident Note dated 5/12/25 documents R1 sustained a fall at 6:20 PM in the facility van. R1 is alert and orientated to person, place, time, and situation. R1 is rating new onset pain at a 5/10. R1's Progress Note dated 5/13/25 documents V5 Nurse Practitioner was called to evaluate R1 due to accident the day before. R1 was sitting at the nurses' station in his wheelchair complaining of pain in the neck and upper back radiating to the rib area. R1 stated the pain was not controlled by Acetaminophen. V5 requested R1 to be sent to the emergency room for evaluation. R1's Progress Notes document multiple requests for pain medication due to rib pain after the accident on 5/12/25. R1's Progress Note written by V5 Nurse Practitioner dated 5/13/25 documents V5 assessed R1 after a fall with a head strike. R1 complained of neck pain, headache, bilateral eye redness, and rib/chest wall pain. R1 was alert and orientated. R1 indicated when he fell backwards in the van in his wheelchair, he struck his head and blacked out. R1 reported having to deal with a headache and neck pain since the accident. R1 described the pain as bad and throbbing. V5 sent R1 to the emergency room. R1's emergency room documentation dated 5/13/25 documents R1 had a fall in his wheelchair which resulted in a closed head injury and closed left side rib fracture. On 5/12/25 R1 was loaded into the facility van in his wheelchair for transport. The facility driver did not strap in R1's wheelchair. When the driver hit the gas R1's wheelchair flipped backwards causing him to fall from his Page 1 of 3 145371 145371 05/24/2025 Arcadia Care Bloomington 1509 North Calhoun Street Bloomington, IL 61701

F 0689 Level of Harm - Actual harm Residents Affected - Few wheelchair. R1 woke up on 5/13/25 with continued chest wall pain and head and neck pain. The documented clinical assessment documents chest wall tenderness is present which correlates with the radiology report. R1's Radiology Report of the Chest dated 5/13/25 documents R1 sustained a possible non-displaced acute fracture of the left lateral rib number six and clinical correlation is advised. R1's Medical Diagnoses list dated May 2025 documents R1 is diagnosed with Dementia, Major Depression, and Obesity. R1's Minimum Data Set, dated [DATE] documents R1 is mildly cognitively impaired, requires supervision/touching assistance from staff to safely transfer from a seated position, and requires the use of a manual wheelchair for mobility. R1's Medication Administration Records for May 2025 documents prior to the accident on 5/12/25, R1 did not request any as needed pain medication. After R1's wheelchair flipped backwards in the van when being transported, R1 requested pain medication (Tylenol) daily. A new as needed pain medication (Tramadol 50 milligrams) was also added for R1's rib pain on 5/14/25 and then the frequency was increased from every six hours to every eight hours on 5/20/25. R1 has been taking pain medication regularly since the accident. On 5/24/25 at 12:55 PM R1 stated two staff members (V7 Certified Nurse's Assistant) and (V8 Licensed Practical Nurse) came to pick him up from the hospital. R1 stated V7 loaded him in his wheelchair into the facility van. R1 stated she did not provide him with a seatbelt or strap his wheelchair in with the van safety strap system. R1 stated they began to drive and stopped at a stop light. R1 stated as R1 took off from the red light, R1's wheelchair flipped backwards, and he fell back and hit his head. R1 stated the fall hurt his head, neck, and he felt it all through his body. R1 stated he has been having pain ever since the accident and for the first two days it was hard for him to get out of bed. R1 stated he has had chest wall pain on both sides, but it often hurts more on the right side. R1 stated he was sent to the emergency room the day after the accident, and they told him he had a fractured rib. R1 stated before the accident he rarely had pain but since the accident he has had pain every day mostly in his chest when he breaths more deeply. R1 stated he went from not taking any pain medication to taking pain medication every day. On 5/24/25 at 1:04 PM V8 Licensed Practical Nurse stated she went with V7 Certified Nurses Assistant (CNA) in the facility van to go pick up R1 from the hospital. V8 stated when V7 started driving after stopping at a red light, R1's wheelchair flipped backwards and R1 was on his back. V8 stated her and V7 helped get R1 back in his wheelchair in the van and they took him back to the facility. V8 stated R1 complained of a headache at the time. V8 stated she was never trained on how to properly secure a resident in the van for transport. On 5/24/25 at 1:31 PM V7 Certified Nurses Assistant (CNA) stated she was asked to pick up R1 from the hospital on 5/12/25. V7 stated she had transported residents before however V7 stated she had never been trained on how to properly secure residents in wheelchairs in the facility van. V7 stated as she drove back to the facility, R1's wheelchair flipped backwards, and he was on his back on the floor of the van. V7 stated she went back to check on R1 and he stated he felt like he was having a heart attack, his neck, head, and chest hurt. V8 helped get R1 back into the wheelchair and they returned to the facility. V7 stated the accident happened about 6:20 PM and R1 continued to complain of chest wall, head, and neck pain for the rest of her shift which ended at 10:00 PM. 145371 Page 2 of 3 145371 05/24/2025 Arcadia Care Bloomington 1509 North Calhoun Street Bloomington, IL 61701

F 0689 Level of Harm - Actual harm On 5/24/25 at 3:45 PM V2 Director of Nurses (DON) confirmed V7 and V8 failed to properly secure R1 in the wheelchair during transport in the facility van on 5/12/25. V2 confirmed this caused R1's wheelchair to flip backwards during transport. V2 confirmed R1 has had pain on his chest wall since the accident and the radiology scan completed on 5/13/25 documents R1 sustained a possibly acute left sixth rib fracture. Residents Affected - Few 145371 Page 3 of 3